High Utilizers and Social Support

There is a common theme within the readmission reduction community that a large number of readmissions are due to limited social network around patients and only if we can provide patients with resources in community, we will be able to decrease these readmissions. Some observations studies have noticed a decrease in readmissions when patients are provided access to social/community resources, however, such studies are limited by risk of bias due to the ‘regression to the mean’ phenomenon.

Regression to mean phenomenon stipulates that if we examine participants once only performing a certain activity (or for an outcome), some of them will perform better while others will perform poorly simply due to some random factors. If we observe these participants longitudinally, we will find that those who performed well will perform poorly while those who performed poorly will perform better than their initial performance. Both groups will try to reach towards their mean (or true value).

Similarly, when we examine high-utilizer patients of health care services during a given period, those patients are likely at their worst and will do better anyway during the follow-up. This has nothing to do with the intervention but rather due to the regression to mean phenomenon. The way to address this problem is either to have several longitudinal measurements of the whole cohort where we can identify regression to the mean or to conduct a randomized clinical trial.

Finkelstein et al., conducted such a trial. They randomly assigned 800 hospitalized patients with medically and socially complex conditions with at least one additional hospitalization in the preceding 6 months, to either usual care (control group) or to the intervention group where social workers and community health workers coordinated and helped patients to access community resources.

To their, and frankly everyone else’s, surprise, they found to benefit of all the efforts of social workers and community health workers in reducing readmissions. The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group. The adjusted between-group difference was not significant (0.82 percentage points; 95% confidence interval, −5.97 to 7.61).

More importantly, study highlighted the phenomenon of regression to the mean showing that the patients with high readmission rates resulting in enrollment generally had a decline in their readmission rate irrespective of whether they received intervention or not.

The study has few caveats but still raises very important questions – what should hospitals, healthcare systems, physicians, and other healthcare team members do to reduce readmissions and healthcare resource utilization in a very vulnerable population.